Vulvodynia

2012
05.09

“Vulvodynia” means pain in the vulva and we use this term to refer to chronic pain not caused by infection, injury or skin diseases. Other terms used include provoked vestibulodynia, vulvar vestibulitis, vulvar vestibulitis syndrome (VVS), vulvar dysesthesia and dysesthetic vulvodynia. Most women with vulvodynia describe the pain as burning or aching and say it is worse with sexual intercourse, inserting tampons and pelvic exams by doctors. Doctors diagnose it by checking for other causes of pain, such as yeast infections or dermatitis, and by doing a “pain-mapping” exam. The doctor touches each part of the vulva lightly (usually with a cotton swab) and finds out which parts hurt and which do not.

We do not know what causes vulvodynia, but it probably involves irritation or inflammation of the skin nerves. The most common treatments used for vulvodynia are creams which reduce inflammation. For short term problems, we use steroid creams and for longer term we use gabapentin. Unfortunately, they do not work well enough for most women. There are other treatments, including physiotherapy, mindfulness, hormones, painkillers, Botox injections and surgical removal of the painful area, but many women still have pain.

Vulvodynia is a chronic pain syndrome that affects the vulvar area and occurs without an identifiable cause or visible pathology [1,2] It is categorized in the ICD-9 codes as group 625—specifically ICD-9 625.7,[3]. Other terms used include provoked vestibulodynia, vulvar vestibulitis, vulvar vestibulitis syndrome (VVS), vulvar dysesthesia and dysesthetic vulvodynia. (Note: The vestibule is the region immediately surrounding the opening of the vagina and the urethra.)

Vulvodynia may be the main cause of dyspareunia in pre-menopausal women with reported prevalence rates of up to 15% in general gynecological practice [4]. This syndrome is characterized by severe pain on vestibular touch or attempted vaginal entry, point tenderness to cotton-tip palpation of the vulvar vestibule, and physical findings confined to vestibular erythema and non-specific inflammation [5] Irritation and burning can persist for hours or days after sexual activity, and many patients also report localized pain from tampon use, finger insertion, gynecological examinations, wearing tight clothing and exercise.

There is no known cause but Allele 2 in the interleukin-1β gene has been reported to be more common in women with vulvar vestibulitis syndrome than in other women. [6]

Sensory nerves that cover the skin surface are peptidergic (protein producing). The proteins that they produce are cytokines (Proteins that act on other cells to stimulate or inhibit their function). The type of cytokines produced by the sensory nerves depends on whether they are healthy or irritated. When these sensory nerves are irritated, they produce Substance P (SP), which is pain producing, and other unfavorable cytokines such as calcitonin gene related peptide (CGRP) and neurokinin A.[7,8] These proteins are called neuropeptides as they are produced by nerves. A simple definition of neurogenic inflammation is the “release of neuropeptides from nociceptors.” [9]